Evidence-based Medicine

Journal Club

Khalid Bin Abdulrahman

Director of Medical Education Center
King Saud University
 A brief overview of EBM
Tips on how to conduct EBM Journal Club
 Practicing Medicine

"the conscientious, explicit andjudicious use of current

best evidence in making decisions about the care of
the individual patient. It means integrating individual
clinical expertise with the best available external
clinical evidence from systematic research."

David Sackett
 Steps in the EBM process

1. Start with the patient and a need for information

2. Formulate a relevant, answerable question

3. Select the resource and conduct a search

4. Appraise the evidence for its validity and applicability

5. Return to the patient -- integrate the evidence

1. Start with the Patient
You Already have seen 6 kids under the
age of 2 years with Otitis Media at your
family practice. Your experience from
Pediatric clinical rotations and your
memory of Pediatric textbooks indicates
that Amoxicillin for 10 days is the
accepted treatment for this problem.
But you are also acutely aware of the
consequences of over-prescribing
antibiotics and the possible adverse
effects of the drug. You wonder if it is
really necessary to treat every
occurrence of Otitis Media with
Amoxicillin, especially in this age group.
 2. Formulate the question

Patient
Intervention
Comparison
Outcome
Type of Question
Study Design
Richardson,W.S., Wilson M.
ACP Journal Club 123:A12
Nov-Dec 1995
study design
 Formulate the question
Patient Otitis Media, 2 yrs old
Intervention Amoxicillin
Comparison no meds, placebo
Outcome reduce fever, pain, long term
benefit
Question therapy
Study Design randomized, controlled
clinical trial
The well built clinical question is:

In children under the age of 2 years presenting

with Otitis Media, does Amoxicillin significantly
reduce fever and pain faster with better long
term results than no medication?

Its a therapy question and the best evidence

would be an RCT.
 3. Select the resource
Ideal information resource:
Valid contains high quality data
Relevant clinical applicable
Comprehensive has data on all
benefits/harms
User-friendly quick, easy to access and
use

see EBM Resource List

Conduct the Search

MEDLINE
TRIP Database
Cochrane
POEMS
ACP Journal Club
MEDLINE
Cochrane Library
TRIP Database
Search on otitis media
the evidence
 4. Evaluate the evidence

Validity
Results
Applicability to the patient
 Validity issues:

Randomization
Follow-up complete (80% or better)
Blinding (concealed allocation)
Baseline similarities
Groups treated equally
 Results of the evidence:

Persistent symptoms at day 4 were present in 59% of

the children in the Amoxicillin group and 72% in the
placebo group. There was a high rate of treatment
failure in both groups after therapy was completed:
64% in the treated group and 70% in the placebo group.

Journal of Family Practice

May 2000
 Applicability of the evidence

Same diagnosis
Same age groups
General practice population
Study done in Netherlands
5. Return to the patient:
Between 7 and 8 children aged younger
than 2 years have to be treated with an
antibiotic for 1 of them to receive a
symptomatic benefit at 4 days compared
with placebo. However, only a small
percentage (30% to 36%) will be
completely symptom free 11 days after
presentation, regardless of antibiotic
treatment. Since antibiotic treatment is
not completely benign and its benefits are
minimal. Most children between the ages
of 6 months and 2 years need not be
treated with antibiotics.